A nurse is caring for a client who is admitted to the medical-surgical unit.
The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.
Temperature
Blood pressure
Hemoglobin and hematocrit
WBC count
Stool results
Current medication
Heart rate
Respiratory rate
Correct Answer : B,C,E,F,G
Rationale for correct choices:
- Blood pressure: The client’s blood pressure is 90/50 mm Hg, indicating hypotension. This can signal volume depletion or active bleeding, which requires immediate assessment and intervention to prevent shock or organ hypoperfusion.
- Hemoglobin and hematocrit: Hemoglobin of 9.1 g/dL and hematocrit of 27% indicate significant anemia, likely from gastrointestinal blood loss. Immediate follow-up is necessary to determine the source and provide interventions such as fluid resuscitation or transfusion.
- Heart rate: The client’s heart rate is 118/min, demonstrating tachycardia. This may be compensatory for hypotension or blood loss, suggesting hemodynamic instability and requiring prompt monitoring and intervention.
- Stool results: Positive hemoccult indicates gastrointestinal bleeding, which aligns with anemia and tachycardia. Identifying and managing the bleeding source is a priority to prevent further complications.
- Current medication: The client takes high-dose ibuprofen (800 mg three times daily), a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs increase the risk for peptic ulcer disease and gastrointestinal bleeding, contributing to the client’s current presentation and requiring immediate provider notification.
Rationale for incorrect choices:
- Temperature: The client’s temperature is 37.5° C (99.5° F), slightly elevated but not indicative of infection or immediate risk. Monitoring is appropriate but not urgent.
- WBC count: WBC is 6,700/mm³, within normal limits, indicating no current infection or acute inflammatory response. This does not require immediate follow-up.
- Respiratory rate: Respiratory rate is 18/min, within normal limits for an adult, and does not indicate acute respiratory distress. Immediate intervention is not necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Case manager: A case manager coordinates overall care and resources for clients but does not provide direct interventions to improve fine motor skills affected by neuropathy.
B. Physical therapist: Physical therapy focuses on improving gross motor function, strength, balance, and mobility, rather than fine motor activities like buttoning clothes.
C. Social worker: Social workers assist with psychosocial support, community resources, and counseling, but they do not address functional limitations caused by neuropathy.
D. Occupational therapist: Occupational therapy specializes in helping clients perform activities of daily living (ADLs) and can provide adaptive techniques or devices to improve fine motor function, such as buttoning clothes, which is appropriate for this client’s needs.
Correct Answer is ["C","D","E","F"]
Explanation
Rationale:
A. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used to treat postpartum endometritis are safe for breastfeeding. Temporary formula feeding is not routinely required.
B. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor, which is not indicated postpartum. It does not treat infection or uterine complications.
C. Monitor the height and tone of the client's fundus: Assessing the uterus for firmness and position helps detect uterine atony or worsening infection. Changes in fundal height or tone can indicate retained products of conception or hemorrhage.
D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing or spreading bacteria to the uterus or perineal area, which is critical when postpartum infection is present.
E. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, decreases uterine congestion, and supports recovery from endometritis by reducing bacterial proliferation in pooled fluid.
F. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: A culture helps identify the causative organism of endometritis, allowing the provider to tailor antibiotic therapy effectively.
G. Initiate contact precautions: Endometritis is not a highly transmissible condition; standard precautions, including hand hygiene, are sufficient unless another communicable infection is identified.
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